AMA Resident Outreach Program Orientation Visit Request Form

The AMA Resident Outreach Program (ROP) strives to increase resident and fellow awareness of the AMA (including its important resources and advocacy initiatives) during resident and fellow orientations.

Complete this form to allow the AMA to:

Host a table at your exhibit or activities fair.

-OR-

Send materials (electronic or print) for inclusion in your orientation kits or distribution at your institution.

Institution Information

*
Denotes a required field
Institution Name
*
Program Name
 

AMA Resident Outreach Program Orientation Visit Request Form

ROP Participation

*
Denotes a required field
Would you like the AMA to visit your institution to distribute AMA materials during your residency orientation?
*
 
 
Yes
No

If yes, please provide detailed information about your orientation or event

Event Date
*
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Event Description
 
(Include any format details, space restrictions, etc.)
Event Attendees
 
Event Time
 
Recommended Arrival Time (if applicable) 
 
 
Event Address
 
City
 
State
 
ZIP Code
 

AMA Resident Outreach Program Orientation Visit Request Form

Event Details

*
Denotes a required field
Number of attendees
*
Estimated number of attendees: (for each day if multiple days)
If event is an exhibit/fair, are residents required to sign-in at each booth or table?
 
 
 
Yes
No
Can we ship materials in advance?
 
 
 
Yes
No
In addition to sharing materials at a table, can AMA materials be placed within your orientation packets?
 
 
 
Yes
No
Is there an opportunity for an AMA representative to speak at your orientation?
 
 
 
Yes
No
If it is not possible for the AMA to attend your orientation, would you like us to send you AMA information that you may distribute to your residents and fellows at your convenience?
 
 
 
Yes
No
If yes, would you like to receive electronic or print materials?
 
 
 
Electronic
Print
Date material is needed
 
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AMA Resident Outreach Program Orientation Visit Request Form

Contact & Shipping Information

*
Denotes a required field

Contact Information

First Name
*
Last Name
*
Phone
*

Shipping Information

Attention
 
(Shipping to the attention of:)
Address
 
Address Line 2
 
City
 
State
 
ZIP Code
 
Any shipping instructions and restrictions